Citation:

Daponte-Codina, A and Knox, EC and Mateo-Rodriguez, I and Seims, A and Regitz-Zagrosek,

V and Maas, AHEM and White, A and Barnhoorn, F and Rosell-Ortiz, F (2022) Gender and
Social Inequalities in Awareness of Coronary Artery Disease in European Countries. Interna-
tional Journal of Environmental Research and Public Health, 19 (3). ISSN 1660-4601 DOI:
https://doi.org/10.3390/ijerph19031388

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Article
Gender and social inequalities in awareness of coronary artery
disease in European countries
Antonio Daponte-Codina1,2, Emily C Knox2, Inmaculada Mateo-Rodriguez1,2*, Amanda Seims3, Vera Regitz-Zagro-
sek4,5,6, Angela H E M Maas7, Alan White8, Floris Barnhoorn9, Fernando Rosell-Ortiz10.
Citation: Lastname, F.; Lastname, F.;
Lastname, F. Title. Int. J. Environ.
Res. Public Health 2021, 18, x.
https://doi.org/10.3390/xxxxx
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name
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Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional
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Copyright: © 2021 by the authors.
Submitted for possible open access
publication under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/license
s/by/4.0/).
Int. J. Environ. Res. Public Health 2021, 18, x. https://doi.org/10.3390/xxxxx
1. Andalusian School of Public Health, Granada, Spain.
2. CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain.
3. Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
4. University of Zurich, Zurich, Switzerland.
5. Charité, Universitätsmedizin Berlin, Berlin, Germany.
6. DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.
7. Department of Cardiology, Director Women's Cardiac Health Program, Radboud University Medical Center, Nijmegen, The Netherlands.
8. School of Health and Community Studies, Leeds Beckett University, Leeds, West Yorkshire, United Kingdom of Great Britain and Northern Ireland.
9. European Public Health Association (EUPHA), Utrecht, the Netherlands.
10. Medical Emergency Services 061, La Rioja, Spain.
* Correspondence: inmaculada.mateo.easp@juntadeandalucia.es; Tel.: +34 670942085
Abstract: Coronary artery disease (CAD) is the single leading cause of death in Europe and the most
common form of cardiovascular disease. Little is known about awareness in the European popula-
tion. A cross-sectional telephone survey of 2,609 individuals from six European countries was con-
ducted to gather information on perceptions of CAD, risk factors, preventive measures, knowledge
of heart attack symptoms and ability to seek emergency medical care. Level of awareness was com-
pared according to gender, age, socioeconomic status (SES) and educational level. Women were
approximately five times less likely than men to consider heart disease as the main health issue or
leading cause of death (OR=0.224, 95% CI:0.178-0.280, OR=0.196, 95% CI:0.171-0.226). Additionally,
women were significantly less likely to have ever had a cardiovascular screening test (OR=0.515,
95% CI:0.459-0.578). Only 16.3% of men and 15.3% of women were able to spontaneously identify
the main symptoms of a heart attack. Almost half of the sample failed to state that they would call
emergency services in case of a cardiac event. Significant differences according to age, SES and ed-
ucation were found for many indicators amongst both men and women. Development of a Euro-
pean strategy targeting improved awareness of CAD and reduced gender and social inequalities
within the European population is warranted.
Keywords: Coronary artery disease; awareness; gender bias; sex differences; inequalities; Europe
1. Introduction
Coronary artery disease (CAD) accounts for 20% of all mortality in Europe and is the
most common form of cardiovascular disease (CVD). According to the latest data, CAD
represents 16% of all premature mortality under 75 years old among women and 18%
among men [1]. Furthermore, there are large differences between countries, with some
European countries having almost 10 times greater rates that others in both men and
women (EU-28). These large inequalities indicate that there is great room for improve-
ment when it comes to reducing the burden of CAD in European countries.
CAD is largely due to a limited number of risk factors, including certain behaviors
[2]. It is widely recognized that improving behaviors such as smoking, following a healthy
diet or engaging in physical activity, can significantly reduce CHD incidence and
www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 2

mortality [3]. Awareness of cardiovascular disease is a hugely important factor when it

comes to individuals making lifestyle changes, adopting preventive measures, and com-
plying with health recommendations and treatment guidelines [4]. Furthermore, aware-
ness of personal risk has been associated with the adoption of secondary prevention
measures by patients, although there is a need to improve understanding of the associa-
tion between health perceptions and cardiovascular preventive behaviors [5,6]. Increasing
awareness is effective for improving the timely and appropriate use of different levels of
health services following coronary events [7]. In short, a degree of basic knowledge about
risk factors, and prevention and protection against CAD within the general population is
essential for improving cardiovascular health [8,9]. The recent COVID-19 crisis has em-
phasized once more that education, socio-economic status (SES), living conditions and
ethnicity are crucial factors in health and this also accounts for CAD [10]. Moreover,
chronic stress induced by air pollution and traffic noise are now also well recognized as
important determinants of cardiovascular health [11].

It is scientifically well established that there are important differences between men
and women at all stages of the CAD process, from risk factors at the prehospital phase to
diagnosis, treatment, rehabilitation and outcomes [4,12]. Moreover, some studies have
shown that women lack awareness of CAD risk factors and symptoms, the impact of CAD
on their health, measures to be taken during a coronary crisis, how to request medical
assistance and options regarding transportation to hospital [13,14].

Furthermore, very few studies have addressed population awareness of CAD in Eu-
rope, in contrast with the long tradition of such research seen in other countries. For all
these aforementioned reasons, the GenCAD project (gender specific mechanisms in coro-
nary artery disease) was developed. This project was aimed at improving understanding
of sex and gender differences in coronary artery disease in European countries.

Within the framework of this project, we carried out a study aimed at determining
levels of awareness within the European population regarding essential aspects of CHD.

2. Materials and Methods

A cross-sectional survey was conducted of 2,609 individuals from six European

countries from November 2017 to March 2018.

We conducted an extensive review of the scientific literature, searching for studies

on awareness of CAD and cardiovascular disease within the general population. Based on
the questionnaires of selected studies [4,8,14], we developed a questionnaire which in-
cluded questions about coronary heart disease, specifically, perceptions of its relevance
for health, risk factor identification and lifestyle behaviors, preventive measures,
knowledge of heart attack symptoms (defined as myocardial infarction or angina pectoris)
and capacity to seek out appropriate emergency medical care. Data were also collected on
basic demographic and socioeconomic details such as sex, age, income and educational
level.

The questionnaire included mostly closed questions, with the exception of questions
on the following topics: CAD as a leading health issue and leading cause of death; heart
attack symptoms and first reaction to suffering a hypothetical heart attack, and; main risk
factors related to CVD. Questions on these areas were open-ended, allowing the sponta-
neous responses of participants to be collected.

The questionnaire was validated through focus groups according to a series of se-
lected criteria in order to evaluate the appropriateness and quality of questions. The final
version of the questionnaire was translated into the six languages corresponding to the
participating countries. Experts in cardiology and other medical specialties, psychology,
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 3

sociology, survey development and public health, from the institutions collaborating on
the project carried out this entire process. The complete questionnaire is attached online
as supplementary file.

Respondents were aged at least 25 years old and came from Bulgaria, Croatia, Czech
Republic, Germany, Spain and Sweden. These countries were selected to represent the
great diversity among European Member States with regards to key indicators such as
CHD epidemiology, economic level, population size, and geographic location.

Within each country, sample distribution was representative of regional variations

in population size and type (towns, cities etc.). Selection of the final sample was performed
according to gender and age quotas. A global market research company, formerly named
TNS (currently Kantar), was subcontracted to adapt the questionnaire into a telephone
survey, translate it into the language of each target country and conduct interviews.
Within each country, households were selected at random using random digit dialing.
Calls were made to both landline and mobile phones in order to maximize representative-
ness. Consent to participate was verbally obtained from participant subjects, after inform-
ing them of the study objectives and procedures. If a participant refused to answer or did
not know how to answer a particular question, responses were coded as “don’t know” or
“no answer”. These participants were not excluded from the analysis.

Data were weighted internally to adjust for differences in age, gender, local area type
and region, and externally to adjust for differences in the population sizes of the six coun-
tries. In this way, data reflected the European population of individuals aged 25 years and
older. Further, it was noted that intra-individual income differences were not comparable
between countries e.g. A monthly income of 1000€ is extremely high in Bulgaria but ex-
tremely low in Sweden. Thus, the socioeconomic variable was transformed to adjust for
inter-country differences relating to income, with participants’ SES being classified as
‘high’ or ‘low’ relative to the median within their country. Remaining variables were
coded, where appropriate, according to the needs of analysis and presentation of results.

Response data from males and females were compared to examine differences in
awareness parameters. Differences within each gender according to age, educational level
and SES were also explored. Detailed results are included on Tables S1-S6 as online sup-
plementary data.

Non-parametric analysis for independent samples was conducted to identify differ-

ences in responses according to gender. The Chi-squared statistic was estimated to exam-
ine the statistical relevance of differences, with significance being set at p < 0.05. No ad-
justments were made for pairwise comparisons. Finally, logistic regression models were
developed to compare the most important awareness indicators according to gender, ad-
justing for age, SES, educational level and whether or not the participant had suffered a
previous heart attack.

3. Results

3.1. Participant characteristics

Overall, 52.2% of respondents were female, 65.7% were aged older than 45 years,
38.3% had undertaken higher educational studies and 41.1% had a high relative SES.
Participants’ demographic characteristics are presented in Table 1 both overall and
according to gender. Female respondents were more likely than male respondents to
belong to the older age group and be divorced/separated or widowed. They were less
likely to report having received higher education (35.5% versus 41.2%) and having a high
SES (36.6% versus 45.9%). Male respondents were more likely to have had a heart attack
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 4

(6.7% versus 4.0%) and have been diagnosed with a cardiovascular disease different to
CAD (12.0% versus 8.9%).

Table 1. Demographic characteristics of respondents to the CAD awareness survey, according to gender.
Male Female Overall
Characteristic N % N % N %
Gender 1252 47.8 1357 52.2 2609 100
Age
25-44 years 425 34.0 469 34.6 895 34.3
45-64 years 514 41.0* 513 37.8* 1027 39.4
65 and over 313 25.0* 374 27.6* 687 26.3
Health status
Very good 261 20.8 280 20.6 541 20.7
Good 637 50.9 686 50.5 1323 50.7
Fair 272 21.8* 325 23.9* 597 22.9
Bad 65 5.2* 52 3.8* 117 4.5
Very bad 17 1.3 14 1.0 31 1.2
Marital status
Single 252 20.2 170 12.6 422 16.2
Married/living together 860 69.1* 894 66.1* 1754 67.5
Divorced/separated 70 5.6** 132 9.8** 203 7.8
Widow 63 5.1** 157 11.6** 220 8.5
Education
Compulsory or less 725 58.8** 860 64.5** 1584 61.7
Higher education 509 41.2** 473 35.5** 982 38.3
Relative socioeconomic status
High 521 45.9** 435 36.6** 956 41.1
Low 614 54.1** 752 63.4** 1366 58.9
Health insurance
Has health coverage 1244 99.4* 1353 99.8* 2598 99.6
Medical history
Has suffered from a heart attack 83 6.7** 54 4.0** 137 5.3
Has been diagnosed with a cardiovascular
148 12.0** 120 8.9** 268 10.3
disease (other than heart attack)
Close relative or friend has had a heart attack 731 58.7* 843 62.5* 1575 60.7
Close relative or friend has had another severe
cardiovascular disease (different from a heart
502 40.9* 589 44.2* 1090 42.6
attack: myocardial infarction or angina
pectoris)
Have you ever taken a screening test to know
about your risk of being affected by 645 52.0** 472 35.2** 1134 43.2
cardiovascular disease?
*p < 0.05.
**p < 0.001.

3.2. Awareness of heart disease

A minority of males (19.2%) and a significantly lower percentage of females (4.2%)

considered heart disease to be a leading health issue, as shown in the results presented in
Table 2. Sex differences were even greater in relation to perceptions of cardiovascular
disease as a leading cause of death (49.9% men vs. 16.5% women).
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 5

Gender inequalities were also examined in relation to age, SES and educational level
(Table 2). Perception of heart disease as a leading health issue and as a leading cause of
death increased with age within both males and females. Further, greater awareness of
heart disease as a leading health issue was seen amongst those with a high SES compared
with those with a low SES (22.7% vs 14.2% for males; 6.7% vs. 3.0% for females), as was
greater awareness of heart disease as a leading cause of death (59.4% vs. 44.2% for males;
19.7% vs.15.2% for females).

These inequalities were starker within men. Differences between the two educational
groups only emerged within women in relation to heart disease as a leading health issue,
whilst for men such differences only emerged in relation to heart disease as a leading
cause of death. Complete results on these inequalities are included as supplementary
material.

3.3. Warning signs of a heart attach and calls to emergency services

Table 2 presents differences in awareness of the warning symptoms of a heart attack

and participants’ initial response to the hypothetical experience of one. Chest
pain/discomfort was the main warning sign reported, regardless of gender. Of the atypical
warning signs, females were more likely to report nausea (12.6% vs. 5.3%) and
palpitations (10.1% versus 8.0%). Only a small proportion of men and women were
capable of spontaneously identifying the most common symptoms of a heart attack
outside of pain (dyspnoea, unusual fatigue, dizziness or generalised weakness) with no
significant differences according to sex (16.3% males vs. 15.4% females). Slightly more
than half of respondents would call emergency services in the event of a heart attack.
Women were more likely to report this response than men (57.6% vs. 54.4%).

Knowledge of common warning signs decreased significantly with age. This

knowledge was significantly higher within those with a high SES relative to those with a
low SES and within those with a high educational level relative to those with low
education. This was true for both males and females. In the event of a heart attack, the
percentage of those who would call emergency services decreased slightly with age.
Within women, differences based on educational level and SES were significant
(education: 67.2% [high] vs 53.3% [low], SES: 64.7% [high] vs 51.9% [low]). Within men,
no significant differences emerged according to SES whilst differences were much smaller
in relation to educational level. Full results can be consulted in the supplementary
material.

3.4. Perceived risk factors and heart disease prevention strategies

 Table 2. Awareness of selected leading health issues, warning signs of a heart attack and responses to signs of a heart attack, according to
gender, education and SES.
High education Low Education High SES Low SES
Male Female Male Female Male Female Male Female Male Female
Characteristic N % N % N % N % N % N % N % N % N % N %
Leading health issue (affecting your gender)
Cancer in general 250 22.8* 235 19.9* 119 26.4ˣˣ 76 18.2 131 20.3ˣˣ 159 21.0 116 22.3 71 16.4†† 133 21.7 151 20.1††
Lung cancer 19 1.8* 1 0.1* 7 1.6 1 0.1 12 2.0 0 0.1 8 1.7 0 0.0 11 1.9 1 0.1
Breast cancer 266 22.5 92 22.2 174 22.9 74 17.2†† 192 25.7††
Diabetes 30 2.8 28 2.4 12 2.8 12 2.9 18 2.8 16 2.2 14 2.7 13 2.9 16 2.8 15 2.1
Heart disease/Heart attack 210 19.2** 50 4.2** 88 19.7 25 5.9 †† 122 19.2 25 3.4 †† 118 22.7ˣˣ 28 6.7 †† 87 14.2ˣˣ 22 3.0††
Obesity 109 10.0* 69 5.8* 54 12.0ˣˣ 31 6.8†† 55 8.8ˣˣ 38 4.7†† 57 11.2ˣˣ 39 9.0†† 52 8.5ˣˣ 26 3.4††
Leading cause of death (affecting your gender)
Accidental death 31 2.7* 5 0.4* 9 1.9ˣˣ 3 0.8†† 22 3.3ˣˣ 2 0.2†† 16 3.3 3 0.9†† 15 2.8 2 0.3††
Cancer in general 260 22.9* 573 49.1* 101 21.4 202 48.7 159 23.7 371 49.2 100 19.1ˣˣ 218 50.1 146 23.8ˣˣ 355 47.4
Lung cancer 42 3.7* 13 1.1* 6 1.2ˣˣ 0 0.0†† 36 5.2ˣˣ 13 1.8†† 7 1.4ˣˣ 1 0.1†† 29 4.7ˣˣ 11 1.4††
Breast cancer 199 17.0 72 17.1 127 16.7 68 15.7 129 17.1
Heart disease/Heart attack 565 49.9** 192 16.5** 259 55.5ˣˣ 75 18.1 306 46.1ˣˣ 117 15.6 301 59.4ˣˣ 83 19.7†† 264 44.2ˣˣ 109 15.2††
Stroke 58 5.1 56 4.8 17 3.8ˣˣ 17 4.2 41 6.1ˣˣ 39 5.3 18 3.7ˣˣ 13 2.9 †† 40 6.9ˣˣ 43 6.0††
What are the warning signs that you associate with having a heart attack?
Chest pain (discomfort and sharp
759 60.6** 779 57.4** 334 65.6ˣˣ 305 64.4†† 418 57.6ˣˣ 467 54.3†† 340 65.3ˣˣ 288 66.3†† 345 56.2ˣˣ 399 53.0††
pain)
Radiation of pain 532 42.5** 659 48.6** 221 43.5 246 52.0† 303 41.8 405 47.1† 237 45.4ˣˣ 241 55.4†† 234 38.1ˣˣ 338 45.0††
Dyspnea (shortness of breath) 219 17.5* 268 19.7* 97 19.1 96 20.4 122 16.8 169 19.7 111 21.3ˣˣ 111 25.6†† 89 14.5ˣˣ 129 17.2††
Nausea 66 5.3** 171 12.6** 36 7.0ˣˣ 68 14.4 29 4.0ˣˣ 102 11.9 36 7.0ˣˣ 42 9.7† 22 3.6ˣˣ 102 13.6†
Sweating 110 8.8** 55 4.1** 51 10.1 22 4.6 59 8.1 31 3.6 58 11.1ˣˣ 17 3.9 39 6.4ˣˣ 33 4.4
Unusual fatigue 60 4.8 64 4.7 18 3.6ˣ 29 6.2† 42 5.8ˣ 34 4.0† 20 3.9ˣ 20 4.7 36 5.8ˣ 38 5.1
Dizziness 180 14.4* 160 11.8* 95 18.6ˣˣ 59 12.4 85 11.8ˣˣ 99 11.5 77 14.7 56 12.8 88 14.4 91 12.1
Generalized weakness 83 6.7* 62 4.6* 38 7.4 22 4.7 45 6.3 40 4.7 33 6.3 22 5.0 45 7.4 39 5.2
Palpitations 100 8.0* 138 10.1* 45 8.9 48 10.1 52 7.2 84 9.8 35 6.8ˣ 48 11.1 58 9.4ˣ 79 10.5

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Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 7

Knows the main symptoms 205 16.3 208 15.4 97 19.1ˣˣ 96 20.4†† 105 14.5ˣˣ 108 12.6†† 102 19.6ˣˣ 89 20.5†† 86 14.0ˣˣ 102 13.6††
If you thought you were experiencing a heart attack, what is the first thing you would do?
Take an aspirin 10 0.8 16 1.2 6 1.2 7 1.4 4 0.6 6 0.7 7 1.3ˣˣ 3 0.7 2 0.4ˣˣ 10 1.3
Go to a hospital 117 9.3 135 9.9 39 7.6ˣˣ 37 7.8†† 78 10.8ˣˣ 96 11.2†† 39 7.4ˣˣ 31 7.2†† 72 11.7ˣˣ 94 12.5††
Call a doctor 187 15.0* 227 16.7* 68 13.4ˣˣ 51 10.8†† 117 16.1ˣˣ 166 19.3†† 77 14.8 59 13.5†† 91 14.9 149 19.8††
Call emergency medical services (112) 681 54.4* 781 57.6* 298 58.6ˣˣ 317 67.1†† 376 51.8ˣˣ 458 53.3†† 286 54.8 281 64.7†† 327 53.3 390 51.9††
Call your spouse or a family member 109 8.7* 94 6.9* 51 10.1ˣˣ 36 7.6 57 7.9ˣˣ 56 6.5 49 9.4 33 7.5 52 8.4 47 6.3
Other 119 9.5* 71 5.2* 43 8.5 21 4.5 68 9.4 50 5.8 60 11.6ˣˣ 24 5.5 47 7.7ˣˣ 38 5.0
Don’t know 28 2.2 33 2.5 3 0.5ˣˣ 4 0.8†† 25 3.4ˣˣ 28 3.3†† 4 0.7ˣˣ 4 1.0†† 23 3.7ˣˣ 24 3.2††
Call emergency services versus all
681 54.4* 781 57.6* 299 58.7ˣˣ 318 67.2†† 376 51.8ˣˣ 458 53.3†† 286 54.8 281 64.7†† 327 53.3 390 51.9††
other options
1 Main symptoms: chest pain, radiation of pain, dyspnea, unusual fatigue, dizziness or generalized weakness. To be considered correct respondents had to provide three of the

aforementioned, of which at least one had to be chest pain or radiation of pain.

* indicates overall comparisons; ˣ indicates comparisons between male subgroups; † indicates comparisons between female subgroups.
*, ˣ,†p < 0.05.
**, ˣˣ, ††p < 0.001.

Table 3. Main risk factors, preventive actions and individuals most at risk of cardiovascular disease, according to gender, education and SES.
High education Low Education High SES Low SES
Male Female Male Female Male Female Male Female Male Female
Characteristic N % N % N % N % N % N % N % N % N % N %
Main risk factors for suffering cardiovascular disease
High blood pressure 142 11.4** 251 18.5** 81 16.0ˣˣ 109 23.0†† 60 8.3ˣˣ 141 16.4†† 67 18.8 58 13.4†† 75 17.8 65 8.7††
Cholesterol (low good cholesterol or high
74 5.9** 142 10.4** 46 9.1ˣˣ 64 13.5†† 28 3.9ˣˣ 74 8.6†† 37 11.0 32 7.4†† 37 9.4 29 3.8††
bad cholesterol)
Family history of heart disease or stroke 128 10.2** 211 15.6** 65 12.8ˣˣ 108 22.8†† 62 8.6ˣˣ 97 11.3†† 69 18.7ˣ 50 11.6† 59 13.4ˣ 64 8.5†
Smoking habit 794 63.4* 812 59.8* 322 63.2 300 63.4† 455 62.7 499 58.0† 369 60.4ˣ 304 69.8†† 351 48.9ˣˣ 429 57.0††
Drinking alcohol 598 47.8** 376 27.7** 231 45.4 134 28.3 354 48.8 237 27.5 258 37.0ˣ 147 50.6† 262 32.0ˣ 229 45.3†
Diabetes 46 3.6** 99 7.3** 29 5.8ˣˣ 41 8.7† 17 2.3ˣˣ 58 6.7† 22 6.3 20 4.5† 24 5.7 21 3.0†
Unhealthy diet habits 489 39.1 544 40.1 223 43.8ˣˣ 225 47.6 †† 259 35.7ˣˣ 311 36.2 †† 230 44.2ˣ 181 41.5 † 221 36.0ˣˣ 272 36.2†
Not exercising 537 42.9* 542 40.0* 277 54.5ˣˣ 236 49.9†† 258 35.6ˣˣ 296 34.4†† 254 48.7ˣ 226 51.9†† 200 32.5ˣˣ 262 34.9††
Obesity 394 31.4** 501 36.9** 182 35.8ˣˣ 187 39.6† 210 28.9ˣˣ 296 34.4† 207 39.8ˣ 187 43.1†† 153 24.9ˣˣ 162 21.6††
Stress 804 64.2 847 62.4 313 61.4ˣ 313 66.2 † 473 65.3ˣ 529 61.5 † 353 67.7 288 66.3 403 65.6 475 63.1
Other 95 7.6** 226 16.7** 35 6.9 89 18.9† 59 8.2 134 15.6† 35 10.2ˣ 51 11.7 60 15.0ˣ 105 13.9
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 8

Preventive actions
Eating more fruit and vegetables 544 43.4* 626 46.3* 211 41.5 178 37.6†† 324 44.7 437 50.8†† 212 40.6 201 46.1 273 44.4 365 48.6
Physical activity 846 67.6 891 65.9 362 71.2ˣ 339 71.6†† 481 66.3ˣ 543 63.1†† 389 74.7ˣˣ 309 71.0†† 395 64.4ˣˣ 483 64.2††
Regular medical check-ups 351 28.1* 409 30.3* 126 24.8ˣ 152 32.1 220 30.3ˣ 249 29.0 135 25.9ˣ 120 27.5† 191 31.1ˣ 237 31.5†
Keep a healthy weight 472 37.7* 478 35.3* 215 42.2ˣˣ 187 39.5†† 247 34.0ˣˣ 278 32.3†† 212 40.7ˣ 161 37.0 213 34.7ˣ 255 33.9
Not smoking 636 50.8** 638 47.2** 269 52.8 245 51.8†† 360 49.6 378 44.0†† 276 53.0ˣ 223 51.3†† 289 47.0ˣ 316 42.0††
Improve stress management 334 26.7** 321 23.8** 145 28.4ˣ 121 25.5 180 24.8ˣ 200 23.4 148 28.5 120 27.5†† 161 26.3 157 20.9††
Hypertension control 275 22.0** 374 27.7** 99 19.4ˣ 130 27.4 171 23.6ˣ 237 27.6 106 20.3 107 24.7† 136 22.2 217 28.8†
Taking vitamins 18 1.4* 30 2.2* 6 1.2 7 1.4† 9 1.3 23 2.7† 1 0.2ˣˣ 8 1.8 14 2.3ˣˣ 22 2.9
Taking antioxidants 12 0.9 15 1.1 4 0.7 5 1.1 8 1.1 10 1.2 2 0.4ˣ 5 1.1 9 1.4ˣ 10 1.3
Hormone replacement therapy 4 0.3 3 0.2 0 0.0ˣ 0 0.0† 4 0.5ˣ 3 0.4† 1 0.1 1 0.1 2 0.4 1 0.1
Diabetes control 117 9.3* 108 8.0* 44 8.6 28 6.0† 73 10.0 77 8.9† 39 7.5ˣ 21 4.9†† 61 9.9ˣ 74 9.9††
Don’t know 13 1.1 10 0.7 4 0.8 1 0.2† 9 1.3 9 1.0† 2 0.3ˣ 3 0.7 10 1.7ˣ 3 0.4
Individuals who are most at risk of suffering from cardiovascular disease
Men have more heart diseases than
960 80.2** 892 69.9** 417 82.0ˣ 339 74.7†† 542 78.8ˣ 553 67.0†† 443 85.1ˣˣ 312 71.7 461 75.0ˣˣ 517 68.8
women
Men that are highly stressed executive
105 115
professionals are more prone to heart 85.7 86.2 436 85.6 406 85.8 621 85.7 740 86.1 450 86.4 378 86.9 533 86.8 650 86.4
9 1
attacks
Young women, under 50, do not have
310 25.7** 274 20.8** 109 21.8ˣˣ 100 21.3 201 28.4ˣˣ 174 20.6 126 24.1ˣ 78 17.9† 176 28.7ˣ 165 21.9†
heart attacks
In women the probability of heart disease
667 65.2** 830 69.1** 288 68.4ˣ 320 75.1†† 379 63.3ˣ 510 65.8†† 298 63.1 308 70.7 369 66.3 506 67.3
increases after menopause
Only women who adopt behaviors and
290 24.7* 301 22.9* 99 20.5ˣˣ 64 13.7†† 191 27.9ˣˣ 237 27.9†† 122 23.5ˣ 72 16.6†† 167 27.2ˣ 199 26.5††
lifestyles of men will have heart disease
Only women which have brought up
55 4.6 54 4.0 13 2.6ˣˣ 7 1.5†† 42 6.1ˣˣ 45 5.2†† 21 4.0 7 1.7†† 28 4.6 43 5.7††
children will have heart disease
* indicates overall comparisons; ˣ indicates comparisons between male subgroups; † indicates comparisons between female subgroups.
*, ˣ,†p < 0.05.
**, ˣˣ, ††p < 0.001.
 Table 3 presents participant perceptions of the main risk factors and preventive
actions. Overall, stress was the most commonly reported risk factor (63.3%), with no
significant gender differences. However, significant gender differences were found for
most of the reported risk factors. Females were more likely than males to report obesity
and less likely to report smoking, not exercising, and drinking alcohol.

Of the preventive actions, the most commonly cited, regardless of gender, was
engaging in physical activity (67.0%). A number of significant gender differences were
found, with females being more likely to report eating fruit and vegetables, having regular
medical check-ups and engaging in hypertension control practices. In contrast, males
were more likely to report maintaining a healthy weight, not smoking and better stress
management.

In general, a greater proportion of those belonging to younger age groups tended to

accurately report the top five risk factors and the main preventive strategies. An exception
to this was found for stress, with differences not being significant. Men and women with
higher SES or with a higher educational level were systematically more able to identify
main risk factors such as drinking alcohol, following an unhealthy diet, smoking and not
exercising.

With regards to preventive actions, a greater proportion of men and women with a
high educational level or high SES reported engaging in physical activity and not
smoking. In contrast, those with a low socio-economic status were more likely to report
having regular medical check-ups.

3.5. At-risk individuals and medical history

Table 3 also presents perceptions about the types of individuals who are most at risk
of suffering from heart disease. A very high percentage of respondents, regardless of
gender, agreed with the statement that “highly stressed executive professionals are more
prone to heart attacks”. Females were less likely than males to agree with the statements
that “men have more heart disease than women” and that “probability of heart disease in
women increases after menopause”, and more likely to agree that “young women, under
50, do not have heart attacks”.

Table 3 also presents inequalities pertaining to medical history according to SES, and
educational level. A significantly higher proportion of those with low SES or with a low
educational level had previously had a heart attack, with differences being particularly
large amongst women. Differences in having had a screening test on CHD risk were not
systematic. The proportion of both men and women to have taken screening tests
increased with advancing age. Within men, differences were significant when stratifying
according to SES but not when stratifying according to educational level. Within women,
the opposite was found with a greater proportion of screening tests being taken by those
with a low SES and low educational level than those with a high SES (36.9% vs. 32.1%)
and high educational level (37.6% vs. 32.1%), respectively.

3.6. Key awareness indicators

Table 6 of supplementary material shows the odds ratios predicting awareness of 11

key indicators in women relative to men, following adjustment for age, SES, educational
level and whether or not one had suffered a previous heart attack. These odds ratios are
presented alongside frequency outcomes in Figure 1. Results show that women were
approximately five times less likely to consider heart disease as the greatest health issue

Int. J. Environ. Res. Public Health 2021, 18, x. https://doi.org/10.3390/xxxxx www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 10

or leading cause of death amongst women (OR=0.224, 95% CI:0.178-0.280, OR=0.196, 95%
CI:0.171-0.226). Further, women were significantly less likely to have discussed with their
doctors about risk factors (OR=0.460, 95% CI:0.408-0.518)., and ever taken a cardiovascular
screening test. No gender differences were found with regards to knowledge of the main
signs of a heart attack, although women were somewhat more likely to call emergency
services than men should they suffer a heart attack. Finally, women in the present sample
were significantly less likely to have had a heart attack (OR=0.536, 95% CI:0.415-0.691).

80 Figure 1. Prediction of selected indicators of awareness 1.5

Males Females

Gender-based odds ratio (men provide reference group)

70 1.3

60 1.1

50 0.9
Percentage (%)

40 0.7

30 0.5

20 0.3

10 0.1

0 -0.1
1 2 3 4 5 6 7 8 9 10 11
Bars represent frequency of males and females reporting variables 1-11. Lines represent gender odds
ratio and associated 95% CI adjusted for age, SES, education and prior experience of a heart attack
(males provide reference group), with the exception of variable 7 which is adjusted for age, SES and
education. Dashed line is OR = 1 i.e. no gender difference.
1: Heart diseases is a main health issue for your gender; 2: Heart diseases is a leading cause of death
for your gender; 3: Would call emergency services when suffering a heart attack; 4: Would call emer-
gency services if somebody else suffered a heart attack; 5: Knows main warning signs of a heart
attack; 6: Has taken a cardiovascular screening test ever; 7: Has suffered a heart attack; 8: Doctor has
discussed risk factors; 9: Would like more information on heart disease; 10: I am informed about
heart disease and the risk factors associated with it; 11: Knows what to do and how to do it, when it
comes to preventing heart disease. p < 0,05 for variables 1-4, 6-8 and 11.

4. Discussion

The present study shows that levels of awareness in relation to CAD in this sample
of the European population are far from adequate. Further, the study reveals that women
have systematically lower awareness than men for many of the studied aspects. Especially
significant in our results is that although CVD is epidemiologically of similar magnitude
for men and women, women give it much less importance than men. This is made worse
by the fact that significant social inequalities also emerged in key aspects of awareness of
cardiovascular health. This was despite the fact that the studied population was familiar
with heart disease, as evidenced by the high percentage reporting having personally suf-
fered a CVD or having a family member or close friend who had.
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 11

Awareness that heart disease is a major health issue was notably low and the major-
ity of individuals also failed to recognise it as a leading cause of death. Similarly, a study
carried out in five European countries almost two decades ago found that less than half
of participants were able to correctly identify CHD as the leading cause of death [15]. It
seems, therefore, that no major changes in CHD awareness amongst the European general
public have occurred, despite the large expansion of medical, epidemiological and pre-
ventive knowledge about this disease over the last 20 years. In the present study, aware-
ness of CHD as an important health issue or as the leading cause of death was much lower
amongst women. Women attribute much less importance to heart disease than it warrants
due to the epidemiological significance of related pathologies within women. This is es-
pecially true when we consider that CVD mortality amongst women in Europe is higher
than their combined mortality from all cancers [1].

It is also of interest that when comparing present results with the results of reference
studies from the USA, it can be seen that the percentage of present respondents aware that
CHD is the leading cause of death is well below the percentage seen amongst American
women [9]. As is the case in other studies, our results show that gender inequalities are
further exacerbated by inequalities according to SES, education and age [16]. Moreover,
in the present study, the outcome of combining inequalities in gender and SES was alarm-
ing. For instance, the percentage of low SES women who considered CHD to be a leading
health issue (3.0% vs. 22.7%) or a leading cause of death (15.2% vs. 59.4%) was seven and
four times lower, respectively, than that of high SES men.

For the population as a whole, CAD awareness is essential for the prevention of car-
diovascular disease and associated mortality. The fact that women give greater relevance
to other health problems with much less epidemiological significance suggests that gen-
der specific effective strategies are needed [4,16].

Pain is the most cited symptom of a heart attack, being reported by just over half of
those surveyed. This result is similar to that produced in other studies [16–20] Although,
respondents were less likely to identify other typical heart attack symptoms, as was the
case in other studied populations, they did identify the most important ones [15,20–22].
Exploring this further, women identified some of the atypical symptoms somewhat more
frequently than men, although differences were small. The lack of differences in relation
to identified symptoms is important as it places women at a disadvantage when it comes
to recognizing and acting in the event of a heart attack since they tend to present with
atypical symptoms [23,24].

In any case, spontaneous knowledge about the set of symptoms that characterize a
heart attack is very low, being even lower in the present study than in studies of other
European or American populations. These differences between studies may be due to the
fact that the present study examined spontaneous responses, whereas other studies were
based on predefined lists of symptoms [21]. Present results show that older people were
less able to identify the symptoms of a heart attack. Results of previously published stud-
ies are not consistent in this regard [18,22,25]. Given that the vast majority of heart attacks
occur at older ages, the consequences of this lack of knowledge could be important. In
addition, correct symptom identification was poorer amongst people with a low educa-
tional level and low SES. This has also been found in other studies [13,17,22,25,26] In the
event of a heart attack, slightly more than half of participants would call emergency ser-
vices. This percentage was somewhat higher within women and those belonging to
younger age groups. Following adjustment for sociodemographic characteristics and pre-
vious heart attack history, the likelihood of calling emergency services was significantly
higher amongst women. In addition, this percentage was significantly lower within men
and women with a low educational level and SES [18,20,25].
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 12

Lack of knowledge of heart attack symptoms was associated with a failure to engage
in the recommended action and call emergency services when suffering a heart attack [18].
Social inequalities both in the recognition of symptoms and in calling emergency services
may significantly contribute to greater delays in receiving appropriate health care [27,28].
This could, therefore, contribute to the already known social inequalities in heart attack
survival [29].

Both males and females reported stress to be the main risk factor for CHD which is,
in itself, relevant for cardiovascular health [30]. Lifestyle risk factors such as smoking, diet
and not engaging in physical activity were more recognized than clinical factors. Signaled
preventive activities reasonably correspond with prioritized risk factors and these results,
in general, agree with those of previous studies and are in line with scientific evidence
and with European recommendations [9,13,31,32].

Furthermore, differences emerged in relation to age. Both men and women were less
likely to identify lifestyle risk factors with increasing age. Findings around the underesti-
mation of this risk with age have already been described in women. Previous studies have
also described how the percentage of women who identify clinical measures as main pre-
ventive measures, such as hypertension and diabetes control, increases with age [4,9].

SES and educational level are important factors when it comes to demonstrating in-
equality in the knowledge of risks and preventive measures [4,13,33]. Present results show
that individuals with a high SES and educational level identified more risk factors and
more preventive actions. In some cases, the magnitude of these inequalities was very sig-
nificant. Outcomes in this regard, however, were not entirely inequivocal. For example,
women with high education and SES identified physical activity in a very prominent way,
whilst women with low education or SES gave more relevance to the consumption of fruit
and vegetables, with inequalities disappearing in relation to this response. This could be
due to differences in awareness, subjective perceptions of personal risk or existing barriers
to the adoption of preventive actions [4,9,13,34].

More than 60% of men and women considered engaging in physical activity to be
the main preventive activity, followed by consumption of fruit and vegetable in women,
and smoking cessation in men. Clinical measures were indicated by less than a third of
participants, with more women than men opting for such responses. The preventive ac-
tions indicated by the present population are in line with scientific evidence and with
recommendations included in European guidelines [31,32]. However, stress control is not
considered as a relevant preventive action, despite being identified as the main risk factor
for CHD. This may be due to the fact that individuals feel that stress is beyond their per-
sonal control as it is associated with adverse life conditions. In other words, the strong
impact of social health determinants on stress means that social and community strategies
are needed to control it [35,36].

Results of the present study also show that doctors are less likely to discuss CHD
risk with women than with men. This may be important in determining sex differences in
awareness [37] as it deprives women of highly relevant information which could assist
them in incorporating positive changes into their lifestyles.

Furthermore, over 80% of participants, irrespective of gender, agreed that “men who
are highly stressed executive professionals” are especially prone to heart attacks. Such a
belief exists despite having no basis in any available scientific evidence [35], denoting a
clear gender and class bias in relation to CHD risk. On the other hand, the fact that almost
70% of women knew that the risk of CHD increases with menopause, regardless of age, is
a much more positive finding, although small inequalities did emerge according to edu-
cational level and SES.
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 13

The present study has some strengths and limitations. The study employed a repre-
sentative sample of the European population. The European Union is made up of a large
number of countries which are highly heterogeneous in relation to key aspects, including
cardiovascular health indicators. Criteria used to select the countries from which the sam-
ple of participants was drawn were based on the aspects believed to be the most important
to reflect. Also, the approach taken enabled gender differences to be analyzed, unlike in
most studies on awareness. This allowed us to examine outcomes in relation to the general
population and to women in particular. Furthermore, the social focus of our analysis al-
lowed us to characterize social inequalities in relation to awareness in this population.
Finally, the survey entailed a validated questionnaire which was administered via tele-
phone for feasibility reasons. A methodologically sound approach was taken, employing
cutting-edge technology and managed by one of the most assured companies on the con-
tinent.

5. Conclusions

In conclusion, awareness of CAD is essential for individuals to be able to adopt pre-

ventive actions and healthy behaviors, identify main heart attack symptoms and reach
emergency services on time. We have shown that awareness of the European population
is in need of improvement. Campaigns run in other countries have been identified to have
produced good outcomes and present findings call for their further implementation [9,38].
More importantly, given European advantages of having universal health care systems
integrated within public health policies [39], a strategy should be developed based on the
strong implementation of primary care which includes institutional policy committed to
gender equality. This could be key to reducing social and gender inequalities in health
[40].

Supplementary Materials: The following are available online at www.mdpi.com/xxx/s1, Table S1:
Demographic characteristics of respondents to the CHD awareness survey according to age, Table
S2: Awareness of selected leading health issues, warning signs of a heart attack and responses to
signs of a heart attack, according to age, Table S3: Main risk factors, preventive actions and individ-
uals most at risk in relation to cardiovascular disease, according to age, Table S4: Demographic
characteristics of respondents to the CHD awareness survey, according to socioeconomic status,
Table S5: Demographic characteristics of respondents to the CHD awareness survey, according to
education, Table S6: Prediction of selected indicators of awareness.
Author Contributions: VRZ, AM, AW, IM and ADC conceptualize and organized the project. ADC,
IM developed the methodology and the instruments for the study. ADC, IM, VRZ, AS, AW, FR and
FB participated in the validation of the questionnaire. ADC and IM were responsible for data col-
lection. ADC, IM and EK did the analysis. All authors revised different versions of the manuscript.
All authors contributed to the article and approved the submitted version.
Funding: This research was funded by the European Union, grant number SANCO/2013/C1/008
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki. The study protocol was approved by the Research Ethics Committee of the
Andalusia Regional Health Department School of Public Health, Granada, Spain).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.

Data Availability Statement: The data used for the study is available from the corresponding au-
thor upon request.
Acknowledgments: The authors thank the participants for their collaboration.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 14

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